It’s pretty common in my job to field enquiries re whether hospital inpatients should be seen by mental health even if they decline. It’s not for me to say, of course, that’s articulated elsewhere in legislation (link to Queensland (2016) Mental Health Act here – BTW it’s a 641 page PDF). My job is to do my best in clearly communicating what’s appropriate and legal.
As you’ll see in the brief (16 seconds) video above, it’s good practice to document something re these sorts of enquiries. I usually do a quick SBAR thingy, and then – for completeness – drop a plain-language summary of mental health act criteria (which I have saved as ieMR autotext) into the file entry.
For those interested, a copy of the content of this ieMR autotext is included below.
Discussion re consent vs involuntary psychiatric assessment.
The Mental Health Act 2016 provides a legislative framework for the treatment and care of persons with a mental illness without their consent.
One of the key rights under the Act is that a person is presumed to have capacity to make decisions about their treatment and care, and the right to consent, or not consent, to healthcare.
Involuntary mental health assessment can be imposed by completing a Recommendation for Assessment. This can be completed by a doctor or authorised mental health practitioner who has examined the person within the preceding 7 days.
The Recommendation for Assessment asks for this information:
1. The reasons you believe the person may have a mental illness
2. The reasons you believe the person may not have capacity to consent to be treated for the illness:
3. The reasons you believe that not providing involuntary treatment for the illness may result in: i. imminent serious harm to the person or others; or ii. the person suffering serious mental or physical deterioration
4. The reason you believe that there appears to be no less restrictive way for the person to receive treatment and care for the person’s mental illness
The blog post is not just about the content. The idea behind doing a screen capture video is to show people the advantage of having ieMR autotext options for you/your speciality area. Is there any stuff you find yourself typing into patient notes repeatedly? You’re busy enough – get the machine to do it for you.
This blog has mentioned creating autotext/templates as an advantage that electronic medical records offer previously (here). Recently this has popped-up in conversations again, as members of the nursing team at the hospital I work at aims to get smarter with how we support Assistants In Nursing (AINs) to safely support patients.
A worry I have as a specialist mental health nurse in a general hospital is that AINs are often allocated as a “nursing special” when there are concerns that a suicidal person may abscond and/or harm themselves again, or to support and monitor the safety of a person who is medically unwell because of acute relapse of an eating disorder. These are people with some of the most complex needs in the general hospital, and AINs are the least qualified (and lowest paid) members of frontline clinical workforce. I’ve written about this concern previously (here).
It’s risky business. Risky for the patient. Risky for the AIN. Risky for the Registered Nurse (RN) or Enrolled Nurse (EN) delegating tasks to the AIN.
The Nursing and Midwifery Board of Australia RN Standards for Practice addresses this: “The RN appropriately delegates aspects of practice to enrolled nurses and others, according to enrolled nurse’s scope of practice or others’ clinical or non-clinical roles” [see Standard 6.3].
The Australian Nursing & Midwifery Federation (ANMF) AIN position statement elaborates: “The assistant in nursing assists registered nurses and enrolled nurses in the provision of delegated aspects of nursing care within the limits specified by their education, training and experience. At all times, assistants in nursing work within a plan of nursing care developed by the registered nurse, and work under the supervision and direction of a registered nurse and, where deemed appropriate by the registered nurse, an enrolled nurse.” [see Number 6].
The ANMF position statement on Specialling includes that “all staff providing specialling, regardless of qualification, should receive an appropriately comprehensive handover from the registered nurse or midwife delegating care“, and elaborates that this should include thorough documentation [see Number 7].*
An RN or EN can delegate tasks to an AIN, but they can not delegate responsibility. It is with that in mind that I’m sharing the content of the ieMR autotext/template that I’ve been using for the last few years.
The content below is individualised to the person’s circumstances (ie: additions and subtractions are common). To my slow-typing fingers, it’s helpful to start with a pretty comprehensive framework and tweak it from there.
Hopefully you’ll note the intentionally non-technical language and tone. The aim is to have a document that clearly describes the delegated tasks. To my way of thinking its important to do so in a way that models and promotes understanding, safety and empathy.
INFO FOR AIN SPECIALS
Why is XXXX here?
XXXX has simple explanation of the medical problem, and has recently experienced symptoms of deteriorating mental health, including: – – Context/contributing factors for this include: – –
Why am I here?
To keep XXXX safe.
XXXX is not/is considered to be at risk of intentional self harm, and/but is at high risk of absconding/misadventure.
For XXXX’s protection they have been placed under a Recommendation for Assessment which expires @ Treatment Authority – this is a part of the Mental Health Act that allows the hospital to keep people in hospital even if they want to leave – if XXXX were to insist on leaving it is not you job to physically restrain them; it is your job to let the RN/TL know immediately
What should I do?
1. Introduce yourself by name and role at the beginning of the shift.
2. One of the first things you should do at the beginning of your shift is to do a thorough scan of the room to make sure there are no sharps (eg: scissors, syringes with needles insitu) or other potentially risky items in the room. It’s a good idea to re-check the room after any procedures/interventions (eg: after wound care, cannula insertion).
3. Ask XXXX if there are any specific concerns that they need a hand with now. They may speak of unrealistic ideas: please use your judgement and liaise with RN/TL if unsure.
4. XXXX does/does not need to be supervised in the bathroom/toilet.
5. XXXX does/does not have to stay in bed, but/and can not leave the ward.
XXXX may find this frustrating – it’s OK to make it clear that this is at the insistence of the Mental Health team.
6. Meal Support (highlighted because this is really important for XXXX) – if you have not done the course already, please go to iLearn and do the online training called “The Shared Table” ilearncatalogue.health.qld.gov.au/course/1493/the-shared-table – it’s also available via EDQ: edqsharedtable.com.au – the key message from the course is that distraction and/or mindful calmness assist at meal times. Please encourage bathroom use PRIOR to meal times, and discourage bathroom use for 30 minutes AFTER meal times. Meal completion times: – 20 minutes for snacks, then – if snack not completed – on to supplementary nutrition as ordered – 30 minutes for meals, then – if meal not completed – on to supplementary nutrition as ordered Documentation of meal completion: – please complete the nutrition chart after each meal – if unable to complete meals, please let the RN know so that s/he can facilitate supplementary nutrition as per Dietitian’s plan
7. Naturally, it’s OK to have a chat with with XXXX. Wondering what to talk about? Try these ideas: – steer conversation away from dark and depressing topics towards the more everyday and cheerful topics (eg: current news stories. movies, TV shows, sport, pets/animal, books, the weather, hobbies/recreation activities, travel/holidays) . This knack for friendly, distracting conversation is known as “Phatic Chat”, more info via meta4RN.com/phatic – sometimes simple hand gestures and body language can be used to help people slow down and get their thoughts organised – it’s probably obvious to you already, but just in case: it is inappropriate to share your personal experiences of mental health problems/recovery, or talk about your religious/spiritual beliefs. That boundary between our personal lives and professional lives is important. One last thing on this topic: it’s very important to be aware that talking about food/diets/weight loss/exercise/physical appearance and related topics with someone who is experiencing disordered nutrition can cause harm.
8. Aim for a low stimulus environment. When experiencing agitation it is helpful if there is not too much noise or stimulation. – one of the strategies for this is to sit in the TV/sun room, rather than stay in the shared room all the time – if a single room will become available, that would be helpful too
9. Stay close enough to ensure that XXXX doesn’t leave hospital doesn’t harm themself doesn’t harm anyone else who is vulnerable (this includes you) – although we are not expecting you to be in harm’s way, it is always sensible to be closer to the door than the person you are caring for: sometimes we need to leave the room quickly to keep ourselves safe from a physically agitated person – if XXXX is tiring of having company and/or is sleeping, it is fine to move your chair outside the doorway, rather than in the room
10. Sometimes XXXX gets a bit sweary. Mostly this is not verbal abuse directed at you, but is just “lalochezia” (emotional relief through using foul language). More about that via meta4RN.com/lalochezia
The mental health team will be reviewing XXXX daily. If there are any changes in expectations for the Special AIN we will update this info sheet.
If you have any suggestions on changes to these guidelines, please jot them down – we can modify this info sheet PRN.
Thanks very much for looking after XXXX – you are playing an important part in their recovery.
Paul McNamara Clinical Nurse Consultant Consultation Liaison Psychiatry Service ext 99999
That’s it. Thanks for visiting.
If you have ideas for improvements, please contribute them below in the comments section – wiki style 🙂
*Addit on 17/07/22: Many thanks to Tara Nipe for bringing the ANMF Specialling position statement to my attention. BTW: It’s worth checking-out Tara’s blog, Twitter and general online profile. Tara’s one of the Australian pioneers of nurses on social media.